Spinal Cord Injury

Overview

A spinal cord injury (SCI) can have profound effects on a person’s quality of life including fertility and sexual function. Sexuality is an important part of a person’s identity as it relates to self-image and interpersonal relationships. The majority of men with a SCI experience changes in fertility and sexual function due to physical function, sensation, and/or response to stimulation.  

Symptoms

Men may undergo a spectrum of emotional and psychological changes after a SCI as they navigate through the rehabilitation process. As they begin to establish a new normal, and explore their sexuality, they may experience an inability to get or maintain an erection (erectile dysfunction), or difficulty ejaculating depending on the type and level of their injury.

In addition to presenting with sexual dysfunction symptoms, men may also present for an infertility evaluation either due to problems with ejaculation, or decreased sperm counts

Causes

Sexual Function

Men have two types of erections, psychogenic and reflex. Psychogenic erections occur with auditory, mental, or visual stimulation. Upon stimulation, the brain sends a message to the nerves of the spinal cord at the T10-L2 level causing the penis to become erect. Men with an incomplete injury at a low level are more likely to have psychogenic erections than men with high-level, incomplete injuries. Men with complete SCI are less likely to experience psychogenic erections.

A reflex erection is an involuntary response that occurs with physical contact to the penis or other erotic areas. It does not require psychological stimulation like a psychogenic erection. The nerves that are necessary to have a reflex erection are located in the sacral area of the spinal cord at the level of S2-S4. Most men with a SCI are still able to have a reflex erection with physical stimulation unless the S2-S4 pathway is damaged.

Lastly, men with a SCI may experience spasticity, which can interfere with sexual function. Spasticity may increase with sexual stimulation leading to autonomic dysreflexia, which may require temporary cessation of sexual activity. Interestingly, ejaculation may decrease spasticity for up to 24 hours.

Fertility

Over 90% of men with a SCI report a problem with ejaculation. Ejaculation requires the spinal cord segment between T10-L2 to be intact. Problems with ejaculation can affect sexual satisfaction and fertility. Men may experience anejaculation (the inability to ejaculate), or retrograde ejaculation (ejaculate moves backward into the bladder rather than out the penis). Sperm that mixes with urine in the bladder will leave the body during urination without causing any harm, but can make it difficult to get your partner pregnant.

In addition to ejaculation, men with a SCI can also have fertility issues related to sperm production and the quality of sperm. Sperm counts can drop dramatically during the initial period after a SCI, but may improve over time in some individuals.

Diagnosis

Your healthcare provider can make a diagnosis of erectile dysfunction based on your history, particularly if you had normal erectile function before your SCI. When discussing it with your healthcare provider, it is helpful to have information regarding the level and extent of your SCI. Depending on your history and other medical conditions, your healthcare provider may also check your testosterone level or perform a penile Doppler ultrasound (ultrasound to measure blood flow within the penis).

If you’re having issues with fertility, your healthcare provider will ask you to perform a semen analysis. If no or few sperm are present, an analysis of your urine sample after ejaculation (post-ejaculatory urinalysis) can reveal if retrograde ejaculation is present. Laboratory testing that may be helpful includes total testosterone and follicle stimulating hormone to determine if there is a problem with sperm production within the testicles.

Treatment

Erectile Dysfunction

The type of treatment depends on the severity and extent of the SCI. There are several options available, but men with spinal cord injuries may have special concerns with their use. Please consult your healthcare provider to decide which treatment option is best for you.

Treatments for erectile dysfunction include:

  • Oral medication. There are currently four oral medications approved in the U.S. for the treatment of erectile dysfunction: sildenafil citrate (Viagra®), vardenafil hydrochloride (Levitra®), tadalafil (Cialis®), and avanafil (Stendra®). They may significantly improve the quality of erections for men with an injury between T6 and L5.
    • These medications work to increase blood flow to the penis. They are all similar in effectiveness, but have slightly different side effects.
    • Some medications work more quickly than others; they work within 20-120 minutes of taking the medication.
    • Possible side effects include flushing, nasal congestion, headache, visual changes, backache and stomach upset.
    • Side effects may be more severe in men with low blood pressure at baseline.
    • Drug interactions may also occur with certain blood pressure medications.
    • Men who have a prescription for nitroglycerin should not take these medications.
  • Vacuum Erection Device (VED). The VED is a vacuum pump that causes blood to be drawn into the penis in order to create an erection. This is done by placing the penis into the vacuum cylinder and pumping air out of the cylinder. The erection is maintained by placing a constriction ring around the base of the penis. This ring also prevents urinary leakage that sometimes occurs with SCI.
    • A VED may be difficult to use for men with limited hand function due to their SCI.
    • Both battery-operated model and hand pump models are available.
    • The constriction ring should be removed immediately after intercourse and care should be taken to make sure that a VED does not cause skin breakdown, particularly in cases of limited sensation of the penis.
  • Urethral Suppositories. Transurethral agents, also called intra-urethral agents, are medications inserted directly into the urethra (the tube that you urinate out of). The only FDA-approved urethral suppository is called MUSE® (Medicated Urethral System for Erection), which contains the drug Alprostadil.
    • MUSE works by dilating the blood vessels in the penis causing an erection.
    • Men should use a condom when having sexual intercourse with a pregnant female while using this medication because it can lead to uterine contractions.
    • The most common side effects include a burning sensation in the urethra and pain in the penis.
  • Penile Injection Therapy. Injection therapy involves the injection of medication directly into the penis. The injected medication helps increase blood flow into the penis causing an erection.
    • Injection therapy typically uses a combination of two or three drugs prescribed by a healthcare provider, called “bi-mix” or “tri-mix” for short. The most common drugs are Papavarine, Phentolamine and Alprostadil. This formulation has to be made by a compounding pharmacy, which makes the formulation as prescribed by a healthcare provider, and therefore may not be available through a standard pharmacy.
    • The injections are not painful, as the type of needle used is very small.
    • Penile injection therapy will typically produce an erection within 10 min of injection.
    • The medication injected has to be refrigerated, which can make it difficult when traveling.
    • Most formulations of the medication expire within 30-45 days from the day the medication was made, after which the medication may not be effective.
    • For men with limited hand function, their partner can be taught how to administer the injection.
    • Rarely, patients may experience a prolonged erection that will not go away. In this care you should seek medical attention immediately. To prevent this, you should determine a safe dose with the help of your healthcare provider.
  • Penile Implant. A penile implant is an important treatment option for men with erectile dysfunction who don’t respond to medications or who are unsatisfied with non-surgical treatments (such as oral medications, vacuum devices, injection therapy etc.).
    • During surgery, the strength columns within the penis that normally fill with blood to create an erection are replaced with two cylinders that provide rigidity to produce an erection.
    • There are two different kinds of penile implants, a semi-rigid (partially erect at all times), or inflatable (saline-filled, inflate on demand) device. Discuss the risks and benefits of each with your healthcare provider to see which option is best for you.
    • A penile implant is a permanent surgical procedure that cannot be reversed so it is important to consider all the options, risks, and benefits prior to committing to surgery.

 

Infertility

There are several options available for men with a SCI to who would like to have children. All of the options will require the use of artificial reproductive techniques such as intrauterine insemination or in vitro fertilization.

In intrauterine insemination sperm that have been washed and concentrated are placed directly into the uterus around the time of ovulation. The sperm then need to swim into the fallopian tube to be able to fertilize an egg. The amount of sperm needed for intrauterine insemination is greater than in vitro fertilization and the sperm need to have good motility (the ability to move) to be able to fertilize and egg.

During in vitro fertilization mature eggs are collected from ovaries and fertilized by sperm in a lab. In vitro fertilization can be performed with a much smaller quantity of sperm, including sperm that have poor motility. In vitro fertilization is typically much more costly than intrauterine insemination.

The various options for men with a SCI and infertility include:

  • Penile vibratory stimulation. Penile vibratory stimulation is an inexpensive way to achieve ejaculation at home and is effective in some men with SCI. In vibratory stimulation, a vibrator is applied to the tip of the penis and surrounding area causing vibrations to travel along the sensory nerves to the spinal cord to induce a reflex ejaculation.
    • It is most likely to be successful in men with a SCI above T10.
    • A variety of vibrators and massagers are available. Men with SCI should look for a vibrator device specifically designed with an output power that will induce ejaculation while minimizing skin problems.
    • For men who lack sensation in the genital area, caution must be used to avoid bruising, bleeding or ulceration.
  • Electroejaculation. Rectal probe electroejaculation is a more invasive method than penile vibratory stimulation. It is usually performed under general anesthesia and involves placing an electrical probe in the rectum to produce controlled electrical stimulation to induce ejaculation.
    • It is a relatively safe, effective way to obtain a sperm sample.
  • Testicular sperm extraction (TESE). For men who penile vibratory stimulation and electroejaculation are not successful, sperm can be obtained directly from the testicle using TESE.
    • TESE is a 30 minute procedure that can be performed in the office using numbing medication. A small cut is made in the skin of the scrotum and a piece of tissue is removed from the testicle.
    • The tissue is inspected under the microscope to confirm that sperm are present.
    • The sperm are then stored or cryopreserved for future use with in vitro fertilization.
    • TESE may not be successful in cases where there is a problem with sperm production in the testicle.
  • Donor sperm or adoption. For men who do not have enough sperm to be used for intrauterine insemination or in vitro fertilization, donor sperm (from a sperm bank) may be used instead. Lastly, for those who do not want to use donor sperm, adoption is an option.

Condition overview written by Sevann Helo, MD

Related Conditions

Neurogenic bladder

Normally the spinal cord communicates with the bladder to control urination. When the spinal cord is injured, it interrupts the signal between the brain and bladder. Neurogenic bladder is a term used to describe urinary issues in people who lack bladder control due to a brain, spinal cord, or nerve problem. It can result from a variety of conditions including a SCI, spina bifida, a stroke, multiple sclerosis, Parkinson’s, and Alzheimer’s disease.

Urinary and sexual function contribute to a person’s quality of life. Urinary function after SCI can have a significant impact on sexual function and satisfaction.  There are several different ways to manage neurogenic bladder depending on whether it’s a problem with storing urine in the bladder, or emptying it. Discuss the options with your healthcare provider to develop a plan that works well for you.


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